Alice Dreger, Ph.D, does social justice work in medicine and science, particularly in the field of improving treatment of "people born with norm challenging bodies." She asks: Why not change minds instead of bodies? Currently she is Professor of Clinical Medical Humanities and Bioethics at the Feinberg School of Medicine, Northwestern University (Chicago).

Last Friday, the New York Times published her essay concerning the Caster Semenya situation at the World Track Championships in Berlin. Here she answers questions related to Semenya and individuals born with possibly similar conditions. [Photo courtesy of Alice Dreger.]

Runner's World: What is intersex, and what does it have to do with sports?

Alice Dreger: "Intersex" is a blanket term used for when someone is born with something other than the standard-male or standard-female anatomy. In some cases, this means a person has "sex chromosomes" other than the simple XX (usually female) or XY (usually male) types. In some cases, it means she or he has genitals that are in-between. (You can't have both sets of genitals, by the way, but you can have something in-between male and female.) In some cases, it means she or he has a female body on the outside but a mostly-male body on the inside, or vice versa. In sports, this comes to matter if someone is playing as a woman but suspected of being a man. In that case, sometimes (though not always), the athlete in question has an intersex condition. There are many different kinds of intersex conditions. Today, the medical establishment calls these disorders of sex development, or DSD for short. I summarized some of the many possible variations in sex anatomy in my editorial in the New York Times.

RW: I think a lot of people will accept that a "drop your jeans" test probably isn't enough. But there used to be a buccal smear test for chromosomes, which is what many of us were taught form the core male-female differences. Why doesn't a chromosome test work?

AD: Because sometimes a person with XX can develop essentially as a male, and sometimes a person with XY can develop essentially as a female. Genes are more complicated than they at first appear. Additionally, some people have a mix of both XX and XY chromosomes. And some people have combinations like XXY (Klinefelter's Syndrome). So it isn't so simple. You can't just look at chromosomes. You have to look at individual genes, actual development of the inside and outside of the body, hormone production at various parts of development, and so on. Sex is really complicated.

RW: Clearly the Caster Semenya situation has been mucked up by being allowed to get to the level of a world sports story. In your opinion, what should be done at this point?

AD: I would hope at this point that the IAAF recognize that they are putting women's athletes personal and professional lives in danger by playing by unclear rules when it comes to sex verification. As I indicated in my editorial in the New York Times, I think it is critically important that the governing bodies of sports come to an open and explicit agreement about how they're going to rule who counts as a woman and who counts as a man. Interesting, they've already done this with regard to trans-gender people, i.e., people who have consciously undergone sex-changing medical treatments. They have clear rules for how long after sex transition an athlete must wait before she can play as a woman. But they have yet to deal with the question of how to sort out sex variations for other people. It's critically important that athletes know what rules they're facing, whether that's in the high-jump or in sex verification. That way an athlete can know what to expect, and not be subject to stigma-inducing international questioning, as Semenya has been.

RW: In track and field, record keeping is very old and very precise, and we have come to expect the best men to be 10 to 11 percent faster-stronger, etc, than the best women. This seems to be because of the strength-power advantage conferred by the male's higher testosterone. Are there rare medical conditions where a female would be born with greater testosterone producing or responding hormones that would give her a big advantage over other female competitors? If so, what should sports bodies do about this?

AD: There are known conditions where women make more androgens than the typical amount. For example, there's Congenital Adrenal Hyperplasia. Usually this condition is diagnosed and treated, though. But here's the thing: Levels of hormone production and level of response to hormones naturally varies in men and women. We should not be surprised that women (and men!) athletes on average may be higher androgen-producers or responders; that's probably part of why they succeed in athletics. What should sports bodies do about this? Recognize that human variation is inevitable and usually accepted in sports! Why should natural hormonal variation be treated any differently than height variation, vision variation, or variation in terms of processing of oxygen?

RW: In your New York Times Op-Ed piece, you suggest that the IAAF needs "a clear set of rules for sex typing." What should those rules say? Will they produce a "fair playing field" for all women athletes?

AD: Whether they produce a "fair playing field" depends on what they say. I am not sure what they should say, but I do think that the IAAF needs to come up with clear rules by engaging intelligent scientists who can help them develop those rules. (I would be happy to help as someone with a long historical perspective, though in general I think the IAAF should rely on sex scientists.) And those rules need to be presented in draft form for review by other scientists. When this happens, everyone will have to face how incredibly complicated sex really is. And that will be a good thing for the whole world. Most people with atypical sex types are not athletes, they're just "average" people, and they would benefit from having some public recognition of how their body types are natural variations on a theme. It's a great opportunity to do some sex education for the whole world.

RW: How did you get interested in intersex issues?

AD: My graduate advisor suggested I look historically at how doctors and scientists had tried to manage people born with unusual sex anatomies. Once I started looking at the literature, I was stunned to realize how common this is. That led me to wonder why I had never heard of it before. As it turns out, a kid I grew up with had an intersex condition, but it was covered up in a veil of shame, so I didn't know it. I started publishing histories of this issue, and then people with intersex asked me to help them change the medical establishment's approach. So I worked on that for about a decade, mostly through the Intersex Society of North America.

AD: It turns out that sex is, in reality, very complicated, even though humans in Western culture (Europe and North America) have liked to believe that humans just come in two clear types. Doctors and scientists, being part of that two-sex culture, have done everything they can to try to force people who are in-between into one of the two clear types. Intersex people themselves have also generally wanted to fit into one of the two clear categories; most are not interested in being in a "third" type. What I found is that doctors will try, generation after generation, to come up with scientific-sounding solutions, but that in reality, there isn't any natural way to divide sex types. You just have to come up with a decision that does what you want the decision to accomplish. That's what doctors have done, and that's what sports officials are now trying to do. The best thing to do, I think, is to admit that variation is natural and that our categories are invented for social purposes. I think it is fine to do that--invent categories. We do it when it comes to age, for example, when we come up with a voting age, a drinking age, an age for consent to sex. I think it is fine to have sports divided into men's and women's, just as it is fine to say a fifteen-year-old is incapable of consenting to sex. But we should recognize these are social distinctions based on biology, and not categories foisted upon us by nature.